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| Entered date | Event description | |
|---|---|---|
| ENS 41161 | 29 October 2004 16:52:00 | During the interlock check of a JL Shephard Model 1 Number 68-10 Irradiator, the source rod was lifted with the machine in the off position, indicating a failure of the interlock. Exposure determinations of the technicians present indicated an exposure less than reportable limits. An investigation is in progress. |
| ENS 40387 | 11 December 2003 14:06:00 | On 11/24/03 a patient was administered a thyroid uptake dose of 0.98 millicuries. The prescribed dose was 0.015 millicuries. The misadministration apparently occurred due to the prescription order being made incorrectly with no subsequent verification. The patient and the patient's physician were notified on 11/26/03. No adverse effect to the patient occurred as a result of the misadministration. |
| ENS 40056 | 12 August 2003 19:10:00 | On June 23, 2003 at 3:30 PM the (University of Kentucky) radiation safety office received a call from an AU (Authorized User) in the Dept. of Biology, because a shipment of I-125, triiodothyronine, 100 microcuries, had not been received. Upon review of the records it was found that the package had arrived on June 18, 2003, and had measured 10 (millirem)/hr at the surface, 0.1 (millirem)/hr @ 1meter, and no external contamination. The Radiation Safety Office shipping paper record shows the I-125 package was included for delivery to room 109, Research Building 3, on June 19. The required signature of receipt for the package was not obtained. With the DOT shipping labels removed, the greatest likelihood is that the package was put into the ordinary trash. A thorough search of the Radiation Safety Office facilities and vehicles was conducted on June 23. On June 24, the authorized user's lab was searched, including use of a low energy NAI (Tl) detector, as well as all labs where deliveries were made on June 19. No trace of the package or contents has been found. It was concluded that the highest probability was that the package entered the normal waste stream and went to a landfill. Once in a landfill, the I-125 will be sequestered from any contact, and will be essentially non-radioactive in 1.65 years. Assuming worst case scenarios, the dose rate to the torso would be about 10 (millirem)/hr or less, and would have to be held against the body continuously by a single individual for 10 hours to produce a dose in excess of 100 (millirem). Additionally there is no indication or likelihood of intentional or accidental ingestion of the contents since this is not intended for human use. However, if the entire 100 microcuries were ingested by a single individual, as sodium iodide, the thyroid dose would be 78 rem, and the effective dose would be 2.4 rem. While no thyroid dose information has been found for the triiodothyronine form, the effective dose from ingestion of 100 microcuries would be 17 (millirem). Surveys are conducted on a continual basis, if the package did not go to a landfill it would likely be found during monthly use area surveys or quarterly supervisory surveys. No NOV was issued based on the corrective actions taken by licensee to correct deficiencies prior to report completion. |